Bieber

Welcome to the forums. I'm new here too, and also a paramedic student, though I'm about to graduate in December. Can't say I'm the biggest fan of fire myself, but I can't find a thing wrong with someone who wants to expand their medical knowledge. Good luck in paramedic school and glad to have you here.

Just a student, but I'll share my humble opinion if that's all right.

When it comes to not transporting patients, I am perfectly fine with not transporting patients if a certain number of conditions are met. Really, I guess I'm more on the more liberal side of the debate, and I really don't think transport is necessary/should be done with every patient. You have to be careful, though, because like everyone on here has said, it's a huge risk you're taking. Every patient that refuses, we get a signature from and I am very meticulous in my documenting that the patient refused transport, and I also document and tell every patient that if anything changes they need to call us right back. But you know what? A recent court case showed that it doesn't matter IF you have a signed refusal from a patient, you can still be sued and still lose the case if they decide to come back after you. That little refusal of treatment/transport doesn't mean squat in a court of law. It won't protect you one bit.

So, in light of that foreboding knowledge, the absolute safest thing to do is to transport all patients. And if you choose not to, you had better be very thorough in your assessment, very thorough in your documentation, and very sure that you can justify yourself in a court of law if they come back after you. On the same hand, someone on here mentioned that we, as providers, shouldn't worry about things like medical necessity and costs. Well, I disagree with you on that. Yeah, patient care should always be our number one priority, and shouldn't ever be compromised for anything, but it was a world full of people each being unconcerned with costs that led to the inflation of health care, and it will take a world of people to bring those costs down. Unfortunately, the notion of defensive medicine makes it very hard for all providers from paramedics to doctors to follow their instinct instead of tacking on a transport or a couple additional tests to cover their asses. And again, I'm not saying that maybe that's not what we should do, only that I don't know of any studies that show an increased benefit to cost--if anyone knows of any, please share.

Here's an example to illustrate what I mean, the way my protocols and the protocols at the hospital are set up, all penetrating trauma above the knees or elbows is automatically a code red trauma, and all code red traumas at the hospital immediately get a head CT, chest x-ray, FAST and stat labs and the whole trauma team gets mobilized and an OR prepped. Now, I've had a patient before who DID have penetrating trauma to the leg above the knee, and we DID run them code red, but they really weren't code red. It was an isolated soft-tissue injury, with no other injuries or complaints, know arterial bleeding, no loss of neurovasculars, and no fracture. Did that patient really need a stat head CT, chest x-ray, FAST and stat labs? In my opinion, no. Unfortunately, for whatever reason, they took the "Per paramedic discretion," clause out of the trauma alert protocol, and it's no longer my decision. Yeah, we could have called for orders to downgrade him, and I can't recall why my preceptors chose not to, but this is just a point I make to illustrate that simply following protocol isn't always in the patient's best interest. Like it or not, SOMEONE has to pay for the care we provide and the care the hospital provides, and while we should never compromise patient care for that, that doesn't mean that every patient needs an ER/trauma room/head CT/etc..

In the end, it all comes down to you and how strongly you feel about not transporting every patient to the ER. Does every patient need to go? No, of course not. Nobody here would argue that. But should every patient be taken all the same? Maybe. We don't have the ability to rule out a lot of things outside of the hospital. We can check a 12-lead, take a blood glucose, do a pulse ox and a thorough assessment. Except in a few small cases, we can't do ABGs, we can't do an ultrasound, we can't do much else. So it's going to have to be a judgement call on your part. I know that I won't transport every patient I have, and that I will seek other appropriate avenues for them, but that's my certification to risk. If you want to risk yours too, that's your call to make, but you will be risking it every time you don't transport a patient. As always, I would warn to err on the side of caution and transport if there is any question at ALL about the patient's condition.

Please don't lose sight of wanting to go back to school and continuing your education. As you spend more time in EMS you are going to meet many, many people who swear that "one of these days" they're going to go back to school. You're also going to meet many, many people who had the best intentions of going back to school and never did. They will offer you a million and one excuses as to why they can't/didn't/won't/couldn't etc.... They will have all fallen prey to the trap that is EMS. It is a rare thing, indeed, for an EMS-er to say they're going back to school and have it actually happen.

Do not let not going back to school happen to you.

Do not wait too long to go back to school after your finish your bachelor's, either. If PA is your goal, and a worthy goal it is, get into it as soon as you possibly can. Trust me on this. Yes, paramedicine has its moments of excitement. Yes, paramedicine offers a lot of things that a young adult can thrive on. I'll even go so far as to say that it can offer you some limited experience that may help you in PA school (this is a heavily qualified statement that I won't go in to right now as I have an exam to study for). But the sooner you get into an advanced degree program (PA/MD/DO... hell, even if you go to nursing school and on to NP) the better off you will be in the long run.

Please take it from someone who spent many years in EMS and is finally back in school. I should have done this years ago. I should have done this years ago. I should have done this years ago!! I love EMS. I really do. I want to stay active in EMS in some manner for as long as I possibly can. But I should have gone back to school years ago. And I'm glad I finally made it happen.

Good luck.

-be safe

Hey, thanks a lot, Mike. I really appreciate that. I know what you mean by the pressure to stay in EMS or otherwise do things that would hinder my ability to get into PA school. I'm happy to hear you've managed to get back into school, my preceptor is actually in a similar boat; he's been a paramedic for like a decade and is going back now to get his Bachelors and NP and I respect the hell out of you both for going back after so long to do that, but I definitely don't want to end up waiting that long myself. I will be graduating with my AAS/Paramedic this december, and I plan on getting right back into classes come spring 2011 to get this taken care of.

Good luck to you too, and thanks again.

I had a hard time with IVs for a while, finally realized it was my technique that was screwy. I was holding the needle like a dart or a pencil instead of holding it in two fingers perpendicular to them. Since I've refined my technique, I haven't seemed to have the kind of trouble I was before, I'm happy to say. Not to say I don't still miss them (there's more than one patient I've taken to the ER with several new holes in their arms that's probably still cursing my name to this day), but I don't seem to be missing the average or easy sticks anymore. 'Course now I probably just jinxed myself.

I'm not all that familiar with dobutamine, but to my understanding it's similar to dopamine in that it's a sympathomimetic as well. It does sound like, while it's also used for cardiogenic shock, that it's also used for CHF. So yeah, you should be able to use it for non-hypovolemic hypotensive patients, from what I understand. Don't know of any services that carry dobutamine, though.

Hi, Kyle. I'm just a student, and I haven't seen the number of code blues that probably the majority of people on this board have, but if it's not too presumptuous I'll share my opinions, such as they are.

So now to my questions.

How do you guys deal with deaths on the job?

To be honest, I guess I don't. I've had, if I'm recalling correctly, a total of eight codes that I've been involved in. On all but one, I took part in performing CPR at some point, and in the two I've had thus far in my field internship, I intubated both of them, and on the second one was leading the code. I say this just to clarify that I wasn't merely a passive observer (or maybe I was?), but involved in their care in some fashion. Now maybe I'm too green in the job to be affected by it yet, but to be honest they haven't interrupted my day or otherwise affected me emotionally. In the EMS/Police/Fire TV series, Third Watch, there's an episode where one of the new paramedics recounts also feeling nothing for his patient who coded, to which the senior paramedic "Doc" replies something along the lines of, "You didn't know them when they were alive, so it's hard for you to miss them when they're gone." I think this is very true in a lot of ways, at least for me. Now, maybe this will change as I get more experience and run more codes, maybe it won't. In the end, who is it for anyone to decide how we should react to death? We all experience it differently, and hopefully we process it in a healthy way.

Do you cry on scene if someone dies? Maybe a young kid.

Have you cried on scene?

Are you allowed to cry or tear up anyways... on scene or in the back of the ambulance when dealing with patients?

I don't and haven't, and to be honest I, in my humble student opinion, don't think we should cry in the presence of family. Not that it's inappropriate to be sad, or to cry later in the ambulance or back at station or wherever, but for two reasons. First of all, we are there to be calm and collected when no one else is. Family is there and is freaking out and they need to know and see that we are calm, that we are doing (or have done) everything possible to save their loved one, but were unable to. And secondly, and this is more of my own personal take on things, because I feel like if I were to cry in front of family that I would be stealing something from them. It isn't our tragedy, it's theirs. I don't have any definable reason to feel that way but it's how I feel and maybe it will change someday, but not today.

And if you'd like you can talk about how you deal with deaths in your personal life if it's different than on the job.

Like I said before, I think that, at least for me, dealing with the death of someone you knew and loved is different from dealing with the death of someone else. Losing someone you were close to is putting the back cover on a book of memories that will never grow any bigger; precious memories that you held dear and had an expectation of adding to. You have no fond memories of the patient (unless you've run them before or otherwise had the opportunity to really enjoy their company before their passing, even the idle happy chit-chat after you've done what you needed to and now have time to kill en route to the hospital), and no expectation to continue to grow upon them. Again, that's just my take for myself.

"Death is not a tragedy. It's a certainty." "indeed, there are tragic circumstances surrounding many deaths. Some die too young. Some seem totally senseless. Some deaths negatively impact the lives of many people. The circumstances of death can be quite tragic, but death itself is not tragic. It is as much a part of life as is birth."

It just left me thinking.

Thanks for reading.. And thanks for any time reading and responses you may have.

-Kyle

No, thank you. I hope what I've said helps, or at least makes some semblance of sense. As I continue through my internship and later in my career in medicine, I wonder if my opinions will change. I haven't had any peds code on me yet, and I understand that for a lot of people those are the heartbreakers that tear down even the toughest of medics, so I really don't know how I'll react to them. Either way, thinking about death now helps me try to make sense of it and my role in it, both in the death of my patients, my family and friends, and myself.

I'm doing my FI in a county with a large urban city (where all of the posts on my preceptors rotation are located) and a large rural area as well. I've had a little bit of rural experience at some of our posts (we're on a three post rotation) where we respond further out in the county, but most of my experience has been in the city. I'm not a paramedic yet, and I haven't worked in a rural setting (though after I get my paramedic I plan on working both at the service where I'm doing my FI and also at a smaller, rural service as well) but I can offer my limited take on things. Or at least, the reasons why I do most of my treatments in the truck.

First of all, because that is the way I've been instructed. Perhaps not the noblest of reasons, but true nonetheless. I have my own quirks to patient care, and I have my own way of doing things, but I was taught to run calls the way my preceptors run them and so I generally follow their template; not solely because they want me to, but also because I agree with their way of doing things.

Second, why I agree with my preceptors and also prefer to do my treatments in the back of the truck, is for a number of reasons. Now, I don't withhold all treatment until we get to the truck, for example I like to get an initial 12-lead on cardiac patients on scene, put my patients who need the monitor on the monitor, get a blood sugar (if I think it could be a sugar problem, otherwise I get it off the IV needle) and place them on O2 and get my first breathing treatment in if necessary, but I prefer to do most everything else in the truck. I usually save the on scene IV for code blues or symptomatic tachy/bradyarrhythmias because I don't want the line getting yanked while we're moving the patient, and because most of the time we can get them to the truck within a reasonable amount of time if they really need an IV stat (not a lot of high rises where I am, and those that are around I've never gotten a call at).

Also, the vast majority of my patients need three things: an IV, a monitor, and a paramedic to monitor their condition. Most of their conditions are either non-life-threatening, but require vascular access and monitoring, or aren't so acute that I expect their condition to deteriorate in the time it takes me to get them out to the truck. Now, that's not necessarily always the case, my fourth patient on my first day of field internship as a difficulty breather who went from respiratory failure to arrest in about the time it took us to walk all ten feet from the front door to them. In that case, I probably would have preferred to run the code on scene (I'm in favor of not transporting codes, however that's not currently what the service advocates), but we scooped her up, bagged her to the ambulance and took care of things there. Thus far, that has been the only patient I have had who has deteriorated that quickly on me, and even then we were able to manage her long enough to get her into the truck.

The final reason, and this is really an operational/administrative issue, but one I (and certainly others as well) have to deal with, is that scene times are closely monitored and it's my perception that dawdling around for too long can attract unwanted attention. And that's not necessarily bad in se, we're a very busy service and there's a lot of pressure for trucks to have a quick turn around, lest we get short on manpower, but all the same, I wish it wasn't necessarily pushed so fervently. Also, along the same lines as the first, is it becomes an issue of both billing and the continuum of patient care if you treat the patient on scene, they decide they feel great and don't want to go to the hospital, and refuse transport. Not to say they can't change their minds en route, but I think there's less of a willingness to do so when we're already going and also when they find out that we're not a taxi service and they only get two destinations: the hospital, or right where we are when we hit the brakes. I'm not a fan of making patient care decisions based on finances, but at the same time, that same policy DOES also help to discourage patients who decide they're fine after they've been converted from their new onset of a-fib from not going in for further eval at the hospital.

Anyway, that's my take on it, such as it is. To clarify, I'm not saying either way of doing things is wrong (I'm a student, I have no opinion), and I think what's most important is patient care. To me, it seems more like two different styles of doing things. If anything, I'm kind of surprised it's not reversed. The folks with 30 minute transport times have a plenty long transport to do everything they need en route, while those of us in the city are often scrambling to get everything done in the 10-15 minutes we spend with the patient. I'd almost expect urban EMS'ers to do what they need on scene and for those out in the boonies to be loading and going and getting things done en route.

So to clarify, you did not work as a basic or an intermediate yet you fully support and recommend the experience as it is invaluable?

How does that work?

Because I see how hard it's been from me going from no previous field experience to trying to become an entry level paramedic, and I see the other students in my class who have had that experience and how much more comfortable they were going into field internship and familiar with prehospital care and operations. Also, just from my own experience in field internship, I know how valuable every minute of experience on the truck is and how much of a difference it has made in how I thought calls should go before I got to internship and how I think they should now.

I'm interested, too, in the line of questioning AK is presenting.

My questions lie more along the line of you thinking about going to PA or medical school. If PA/MD/DO is really your goal, why are your wasting time with going to school for, but not working, in EMS? (Please don't answer that you think the experience will be invaluable.) Did you finish a college degree? Or is the paramedic education you're pursuing a degree program? Does it provide the academic background needed for you to continue an advanced degree?

-be safe

I haven't worked previously as an EMT, but I do plan to work as a paramedic while I continue my education. To answer your question about why I am doing paramedic, it's because I don't think it is a waste and because I want to be a paramedic. That's not to say that I don't want to continue my education and eventually finish my Bachelors and get into PA school (I have some gen ed courses and the PA prereqs left to finish my Bachelors and qualify to apply to PA school), but that until that time when I can go to PA school, I want to be a paramedic, and I want to work in EMS. Even after I get my PA, I still want to stay involved in EMS because it is where I got my first taste of medicine, and where I think I can contribute to both as a paramedic and as a PA if I get there.

Ok...I will.

Seeing how you present yourself in an educated and impressive manner and do not appear to be a ricky rescue yahoo type...please answer this question which has come up many times on the forums.

Knowing what you do now, almost finished with paramedic school...did you or do you feel better prepared because you went through the various levels of training or do you wish you had gone straight from basic to medic?

You know, I did feel better prepared in some things, but I don't know if you can ever really be all that prepared for all that paramedic school entails, no matter where you're coming from. The one thing I do really wish I had done that I think would have made a huge difference especially in FI is to have actually worked a year as an EMT before getting into the paramedic program. Unfortunately it isn't required by my program anymore but I really see now the value of previous experience as a basic before you go on to paramedic school.

Has your opinions of experience changed?

Didn't even see this question until after I'd answered it! But to expand, experience is everything. I'm what everyone calls "book smart", with no common sense to save my life. But reading about a condition and actually seeing it are two separate things, and one of the hardest things to overcome in internship has been that difficulty in making my brain and my body work at the same time and trying to remember everything I've learned in the heat of the moment, if you will.

Are you glad you spent time as a basic before going to medic school or do you wish you had gone straight into medic school after basic?

Well, unfortunately I didn't spend any time working as a basic but rather dicking around, basically, while I tried to figure out whether I wanted to go to paramedic school or not. But like I said, experience as a basic before paramedic is invaluable.

Did the time as an intermediate "waste" more of your time?

Not at all. The things I learned about acid/base balances and fluid shifts and fluid therapy made relearning and expanding on it in paramedic all the easier. I feel like getting my intermediate first helped me in a lot of ways to be a little more ready for paramedic.

Did you find yourself wishing again you were in medic school?

Well, I'm not quite through yet, I'll be graduating in December assuming I survive the final half of internship, but yeah, I do kind of miss the parts of the program we're already done with; all of the lectures, clinicals. It will probably always feel like there is still so much more I could have learned, but I'm happy with how I've done and where I am and I wouldn't trade the last year and a half for anything.

Were you happy with the level of care and knowledge you had working as an intermediate or was there some disappointment?

Well, I never did get the chance to work as an intermediate, but I was disappointed in the limitations of how much I would have been able to do had I worked as one. I decided to do paramedic because PA/med school isn't a sure thing (not that paramedic was, not in the least) and I felt like, at the very least, I want to be able to provide the best possible care to patients in the prehospital setting, and at the most I wanted to continue my education after working the streets for a few years and continue to provide the best possible care in the in-hospital setting as well. I feel now like, if I don't ever become anything more than a paramedic, that's something I can be happy with and proud of. Since entering medicine, my goal has always to be able to provide the most and best care I could to my patients in whatever setting I'm in, and I think that in the prehospital arena becoming a paramedic was a requirement for me to be able to offer that to my patients.

Would you recommend people skip intermediate?

I would recommend people take it as they work for at least a year on the streets as a basic. Even if you don't intend to practice as an intermediate, the knowledge you gain in the class will "soften the blow", so to speak, in learning some of those things in paramedic school that they don't teach in basic. Ultimately, it's whatever works best for the person, but I can think of no wrong reason to take advantage of more knowledge that will help you or make things a little less foreign in paramedic school.

Would you recommend people skip or not give as much concern to "getting their feet wet before medic school" if their area allows that?

Oh no. Not at all. If your program doesn't require you to work for a year as a basic before entering paramedic school, take a year off beforehand and do it anyway. It is unbelievable just how much experience matters, and you don't want to be spending a lot of time in FI just learning to be a good EMT before you can work on being a good paramedic. Like I said, if I could go back and do it again I would have definitely worked as an EMT before going to paramedic school. Every chance you get to work on a truck with patients is like gold when you go to paramedic school. Its worth simply cannot be understated.

Sleep as much as you can, because pretty soon you won't be sleeping hardly at all.

Just kidding, but you probably will find yourself sleeping a little less than you have been once you start.

I'm in my last semester of paramedic school, so I'll give you what was probably the best advice that was given to me by my program director. In paramedic school, you'll find yourself struggling at first, and then you'll finally reach a point where you've gotten the hang of it and you plateau and you'll start to feel comfortable, and then you'll have to start climbing again. And then you'll reach another plateau, and you'll get comfortable, but it won't last for very long before you find yourself climbing yet again. Every time you reach that plateau and you get to where you feel like you've got the hang of it, you're going to find yourself having to climb and work a little bit more. That's how it has been for me throughout the entire program, anyway.

It's a lot of fun, and if you really want it you're going to find yourself loving every minute of it--even when you're sick to death of it at the same time. It's worth every second, every bead of sweat, and every moment of thinking "I'm never going to get this." Another piece of advice, for the love of everything holy, have your social and family life in order, and definitely have your finances in order. Day one of field internship is not the time to realize that you aren't going to be able to keep a roof over your head unless you can keep working full time at your day job--and trust me, you won't have time for that in field internship.

Thanks for the warm welcome, everyone! I appreciate it and the all the kind words, it's nice to be in such an inviting environment. I look forward to enjoying more discussions with such professionals as yourselves.

Dwayne, my hair may have been slightly Bieberish (though I admit to nothing), but I've since cut it. The nickname's stuck nonetheless.

Sorry about before, I thought you meant emetics like ipecac before. Excuse the brain fart. Yeah, anti-emetics probably would have been indicated. I get what you mean about the fluids for the dehydration secondary to vomiting and alcohol consumption; that time I was just wrapped up in the protocols I'm running under currently. They only allow fluid boluses for hypotension with tachycardia.

Hi, everyone,

I've already posted a couple of replies to some existing threads here, so I thought I should go ahead and introduce myself to the forum. I'm Justin, I'm a paramedic student in the middle of field internship and set to graduate this December. My preceptors gave me the nickname Bieber (and made sure everyone in the hospitals know to address me as such), so feel free to continue the trend.

I live in the midwest and got my EMT-B in 2007, my EMT-I in 2008, and entered paramedic school in 2009. After I finish, I plan to work part time at the service I'm doing my field internship through and possibly part time at one of the more rural services in the area while I continue my schooling and hopefully get into the PA program here.

I originally went to college pursuing a Bachelor's in foreign language when I had a change of plans and decided I wanted to go to medical school instead. Someone suggested I go and get my EMT first to get my feet wet in medicine and it stuck. I went back and forth about whether or not I wanted to go through paramedic school for a while, but I eventually went for it and here I am.

Anyway, that's me, feel free to ask me anything.

I'm just a paramedic student about halfway through my field internship, but if you don't mind I'll share my opinion.

It sounds like the patient was able to maintain his own airway, and I'm assuming was also alert if intoxicated. You had good sats on the NC and he was maintaining his airway, and I'm assuming he wasn't in any respiratory distress so I think it was appropriate not to intubate him; it wasn't really indicated if he could manage his airway and wasn't in respiratory arrest.

As far as I know, anti-emetics are no longer the recommended therapy for poisons, the preferred method is activated charcoal or the antidote for the poison, so I think you were right not to administer anything to him--especially if the patient and family are denying an OD. And I don't really think the NG tube was indicated unless you were thinking about giving him some charcoal anyway just to be on the safe side.

Honestly, and this is just my humble student opinion, but I think your treatment was appropriate, and I don't think I would have done anything different. You kept the patient's airway patent, had him on the monitor and had IV access. Adderall's a stimulant so I think if he was having an OD you would have seen an elevated blood pressure, but you said it was fine. I think that hypertensive crisis and seizure would be the two biggest concerns with an OD of Adderall but you had IV access if he seized and his BP was stable.

I don't know about him being so pale, so he definitely needed further eval at the hospital, but otherwise, like I said, I wouldn't have done anything different. The only question I have is why did you give him the fluid bolus? Did he appear dehydrated or what exactly was it that made you give him all the fluid?

I don't think it's inappropriate to visually inspect the genitalia. Outside of obstetrics I don't think there's much reason to manually palpate the genitalia, but I think it's acceptable and appropriate to visually assess when indicated.